Dear Therapist:

As a rebbe I am often asked to make recommendations for what type of help is best for a bochur. When a child or teenager is struggling socially (but otherwise a pretty normal kid), what type of help is best for him? Is it social skills training? Help with social anxiety? Or is he just maybe an introvert that is best left alone? I know that you can't answer for a child you never met but I am wondering if you could give some general guidelines to help people choose the best type of treatment. Ideally, we could send to one person and they could figure out what it is and provide the best treatment but I find that professionals tend to specialize and focus on one area over the other (i.e. social skills vs anxiety). Thank you for your help. 



As your question is similar to others that have been asked, and the question is non-specific, I will respond by adapting and combining a couple of past responses.

Your question relates not only to treatment modality, but also to focus and specialization. Although the therapeutic relationship is paramount, identifying any problems and their sources are an important factor in determining the need—and therefore the therapist. You can reach out to a referral agency (like Relief Resources, Sephardic Bikur Holim, or JBFCS), or speak with someone who is involved with mental health resources. The more information that they have about the particular child and the specific concerns, the better they can help you to find the right therapist. Therapists who are honest (both with others and with themselves) can also help to appropriately target the issue, allowing them to guide you in the right direction. This can often be done in a relatively short phone conversation.

Each client—and each therapist—has a different personality, different needs, and different preferences. A therapist who has helped one person with a particular issue may not be the right fit for someone else with a similar issue. To some degree, the first couple of sessions help both the therapist and the client to determine whether they are properly matched. This comes down to personality, therapy style, and the ability of the therapist to connect to the client in a way that makes the client feel comfortable. This is the period during which the client can begin to determine whether the therapist’s style and techniques speak to them.

Generally speaking, the most significant factor leading to successful treatment is the therapeutic relationship. This has been shown in multiple studies and meta-studies, and is true for a variety of reasons. Buy-in and motivation, as well as placebo effects are likely primary reasons that the therapeutic relationship is so important, and why it—in and of itself—is so effective a treatment component.

Psychotherapy is different from other forms of therapy (physical, occupational, speech, etc.), and from the field of medicine. The physician-patient relationship is often a factor in successful treatment (one could argue that it always is). Within psychotherapy, this factor is usually greatly magnified. It bears repeating that the therapeutic relationship has been shown to be the most significant indicator of successful treatment (more so than specific treatment style, for instance).

The efficacy of the therapeutic relationship has been established across the board, regardless of the particular therapeutic modality. This should guide us to choose therapists with whom we mesh, and with whom we feel comfortable. When we have a sense that the therapist is warm, understanding, empathic, genuine, and supportive, this can go a long way toward development of a strong therapeutic relationship. This is largely dependent on us, however. Although therapists can do their part to exhibit these qualities, the relationship is ultimately a function of the client’s perception.

Naturally, a prerequisite to a positive therapeutic relationship is the sense of being comfortable with the therapist. If a child goes into the first session with a preconceived level of discomfort, he is more likely to be resistant (consciously or otherwise) to developing a strong alliance. This can greatly reduce the effectiveness of the therapy.

The degree to which the therapeutic relationship affects treatment outcome may vary to some degree depending on the specific issue being addressed. Also, the availability of therapists who treat relatively obscure conditions may be limited. Of course there are considerations other than the therapeutic relationship. A referral agency or other source can help you to identify these. However, without a strong relationship, the likelihood of successful treatment is probably greatly diminished.

-Yehuda Lieberman, LCSW

  psychotherapist in private practice

  Woodmere, NY

  adjunct professor at Touro College

  Graduate School of Social Work

  author of Self-Esteem: A Primer / 516-218-4200


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